Insurance organizations processing medical bills face challenges in balancing compliance with speed and accuracy. Manual workflows slow adjudication, increase administrative overhead, and create risks of human error. With variations in rules across states, insurers must maintain high accuracy and auditability to comply with regulations while still meeting client and claimant needs. To address these challenges, the company deployed Decisions to automate end-to-end bill review, adjudication, and reporting.
Challenge
Before adopting Decisions, the company struggled with:
- Manual Data Entry: Staff entered bill details line by line, leading to delays and high error rates.
- Compliance Burden: State-specific rules were difficult to manage consistently without automation.
- Limited Productivity Tracking: Managers lacked real-time visibility into bill reviewer workloads.
- Operational Bottlenecks: Bills often stalled due to locked workflows or incomplete handoffs.
- Inconsistent QA: Quality assurance sampling was manual and time-consuming, limiting scalability.
Solution
The company leveraged Decisions to create a custom application for automated bill review:
- Bill Entry & Adjudication: Automated application of state-specific rules to provider bills, reducing billed amounts to compliant, allowable charges.
- Reviewer Productivity Tools: Role-based dashboards showing bills worked by reviewer and date.
- Queue Management: Configurable work queues defined for each client, supporting both OCR and web-service-driven bill intake.